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PAM REHABILITATION HOSPITAL OF ALLEN
EMERGENCY SERVICES
Tag No.: A0093
Based on record review and interview, the governing body failed to ensure the facility written policies and procedures were followed in that:
A Memorandum of Transfer (MOT) was not completed and sent with each patient transferred to hospital in 2 of 2 patients reviewed for hospital transfer to the emergency room.
Findings included:
Record reviewed on 12/11/19 at 11:35 a.m. revealed Patient #1 was a 65-year-old male with past medical history of myelodysplastic syndrome, Chronic kidney disease, congestive heart failure and anxiety, admitted to facility on 10/18/19 at 17:48 for an intensive rehabilitation program.
Patient #1 had a change in condition on 10/20/19. Physician was notified and an order to transfer the patient to Presbyterian Hospital at Allen was received at 07:37 with indicated diagnosis of signs of stroke and acute respiratory failure.
Patient #1 was transferred to Medical City McKinney on 10/20/19. A Memorandum of Transfer was never completed and sent with the patient at the time of transfer as per the facility policy.
Record reviewed indicated another patient #2 had a change in condition and physician ordered patient #2 to be transferred to Medical City McKinney on 07/22/19. Memorandum of Transfer was never completed and sent with the patient at the time of transfer as per the facility policy.
During an interview on 12/11/19 at 12:58 p.m., Personnel # 1 was asked for the MOT's for the transferred patients. Personnel #1 stated, "We do not have MOT. I think we should come up with a form for hospital transfers."
In an interview with Personnel #2 on 12/11/19, Personnel #2 stated that no separate record was kept of individuals transferred to the hospital and no such record was available for the surveyor's review
Review of facility policy # NSG 32 titled "Memorandum of Transfer" with revision date July 30,2019 indicated "Memorandum of Transfer will be completed for every patient who is transferred. A copy of memorandum of transfer shall be retained by the transferring and receiving hospitals."